Odontogenic maxillary sinusitis.

Etiology,
anatomy, pathogenesis, classification,
clinical picture, diagnostics, treatment and
complications.
Odontogenic sinusitis - is an inflammatory condition of the paranasal sinuses
that is the result of dental pathology, most often resulting from prior
dentoalveolar procedures, infections of maxillary dentition, or maxillary dental
trauma. Infections are often polymicrobial with an anaerobe‐predominant
microbiome requiring special considerations for antimicrobial therapy.
Anatomy
• The paranasal sinuses are air‐filled cavities that
develop from the facial bones of the skull. These
sinuses are named for the bones in which they
originate. This includes four paired sinuses:
maxillary, ethmoid, sphenoid, and frontal. The
paranasal sinuses are immature at birth and mature
with age. Both nasal cavities have a total surface
area of about 150 cm2.  The resting rate of mucus
production is about 0.5 to 1 ml of mucus per
cm2 over a 24‐hour period. As a result, the paranasal
sinuses produce 75 to 150 ml of mucus per day,
which helps to humidify inspired air and facilitate
alveolar gas exchange. In addition, mucus traps
particulate matter and the mucociliary clearance of
the respiratory epithelium removes mucus from the
sinuses. Patency of sinus ostia and normal
mucociliary function are required for normal function
of the paranasal sinuses. The maxillary sinus is the
first sinus to develop in utero via evagination of the
nasal mucosa into the lateral cartilaginous
environment from the primitive ethmoid
infundibulum.
This sinus is present at birth and demonstrates growth periods from birth to 3 years of age and further
maturation from 7 to 12 years of age. The natural ostium is located in the superior aspect of the
medial wall of the sinus. The ostiomeatal unit is a functional unit involved in the drainage pathway for
and ventilation of the maxillary, anterior ethmoid and frontal sinuses.

The blood supply to the maxillary sinus is carried out by the branches maxillary, facial and ocular arteries. Venous blood
flows into the veins of the same name and the pterygoid plexus. Diverting lymphatic vessels the sinuses drain into the lymph
vessels of the nasal cavity. Innervation is carried out by the optic and maxillary nerves, as well as by the pterygopalatine node.
 Etiology
• Odontogenic maxillary sinusitis (OMS) is most commonly the result of iatrogenic
injury of the mucoperiosteum, or Schneiderian membrane, of the maxillary sinus.
Dental procedures such as dental extractions, maxillary dental implant placement,
sinus augmentation grafts (“sinus lift”), misplaced foreign bodies as well as
orthognathic and cleft surgery procedures have all been associated with odontogenic
sinusitis. Other potential etiologies include periodontal and periapical disease.
Endodontic infections are typically the result of extension of dental caries into the
dental pulp resulting in pulpitis and apical infection. Alternatively, chronic
periodontitis may occur in the setting of chronic infection of a tooth socket. The
resultant inflammation and/or disruption of the Schneiderian membrane leads to
mucosal inflammation and altered mucociliary function within the maxillary sinus.
Impaired mucociliary function results in altered mucus transport, impaired mucosal
defenses, blockage of sinus ostia and resultant bacterial infection and inflammation.
Other less common etiologies of odontogenic sinusitis include maxillary bone
trauma, odontogenic cysts, neoplasms or other inflammatory processes.
Depending on the etiology:
Classification
• odontogenic;
• rhinogenic;
• rhino-odontogenic;
• allergic;
• post-traumatic.
According to data (Timofeev A. 2010), odontogenic sinusitis is diagnosed in 21.3% of cases
of the total number of purulent-inflammatory processes of the maxillofacial region and in 87% of
the total number of sinusitis, rhino-odontogenic - in 3.1% and 13% respectively.

Classification of odontogenic sinusitis depending on the clinical course:

• acute (serous, purulent);
• chronic;
• aggravated chronic

M. Azimov (1977), by the nature of the pathological changes, distinguishes:

-catarrhal;
-purulent;
-polypous;
-purulent-polypous forms of sinusitis.
Pathogenesis and features of odontogenic
sinusitis
Pathogenesis and features of odontogenic sinusitis

1. Limited lesion. With odontogenic sinusitis, the lower and outer walls of the maxillary
sinus are mainly affected, less often - inner wall; the mucous membrane of the upper and
posterior walls often remains intact. The predominant lesion of the lower and outer walls
is explained localization of the odontogenic focus - the source of the disease in the
alveolar the process, which borders on the indicated walls of the maxillary sinus.

2. One-sided defeat. Bilateral disease of the maxillary sinus of an odontogenic nature

and involvement in the inflammatory process other accessory cavities, in particular the
ethmoid labyrinth, we observed quite rarely. Rhinogenous sinusitis is more often bilateral,
which is also often combined with inflammation of other paranasal cavities, up to
pansinusitis. Obviously, an allergic factor, which has a certain value in the pathogenesis
of rhinogenic sinusitis, in the development odontogenic less pronounced.

3. Primary chronic course. Odontogenic sinusitis can be asymptomatic, and they are
diagnosed during the examination for about the underlying disease. As a rule, patients
consult a doctor when the presence of a fistula with purulent discharge on the alveolar
process of the upper jaw (chronic periodontitis and osteomyelitis), the appearance of
protrusion in the area of ​the cheek or hard palate (cysts), liquid write in the nose during
meal time (perforation of the maxillary sinus).
•

Diagnostics
The correct diagnosis of odontogenic sinusitis is helped by a thorough study of
complaints and history of the disease, as well as physical, instrumental and
additional examination methods:
• palpation of the walls of the paranasal sinuses;
• teeth percussion;
• posterior and anterior rhinoscopy;
• puncture of the maxillary sinus with subsequent washing and assessment of
the condition of wash water;
• X-ray research methods (X-ray of the paranasal sinuses in standard
projections, sighting dental X-ray, orthopantomography, contrast X-ray);
• CT scan;
• remote infrared thermal diagnostics;
• endoscopy of the maxillary sinuses;
• Ultrasound methods
Steps in diagnostics
Clinical picture. Acute forms OMS (purulent)
Extraoral clinical picture of patient with left-side
acute purulent odontogenic maxillary sinusitis
 CT-scan image of patient with Left-side acute purulent
odontogenic maxillary sinusitis. Radicular cyst in apex of 26
The pain intensifies and spreads to the
corresponding side of the head. As a
result of edema of the nasal mucosa,
constant symptoms of acute sinusitis
appear: congestion of the corresponding
half of the nose, difficulty breathing and
weakening of the sense of smell. Sick
complain of discharge from one half of
the nose. With a serous form of
inflammation, the discharge is
transparent, in the future the exudate
acquires a purulent character and
unpleasant odor.
 Clinical picture. Acute forms (purulent)
On the radiograph of the paranasal sinuses in standard projections or CT-scans with acute sinusitis
observe darkening of the maxillary sinus of varying degrees of intensity. On sighting radiographs
of teeth the upper jaw determine the focus of odontogenic inflammation. More often it is located in
the periapical region of premolars or molars, less often in canines.
Endoscopic Endonasal
Approach (EEA)
 Treatment of acute odontogenic sinusitis
I step. It is necessary eliminate the
source of infection - remove the
causative tooth and create an
outflow of purulent exudate. In the
treatment of acute sinusitis, puncture of
the maxillary sinus and its washing
with antiseptic solutions (rivanol,
furacilin, dioxydin, chlorhexidine) With
concomitant inflammation of the
maxillary sinus and peri-maxillary soft
tissues open phlegmon, with purulent
sinusitis - sinus puncture through the
medial wall and catheterization.
Treatment of acute odontogenic sinusitis
II Step. Sinusectomy
Successful management of odontogenic
sinusitis involves a combination of medical
treatment, dental surgery and/or endoscopic
sinus surgery. Although several studies have
emphasized dental surgery as the primary
treatment modality for odontogenic sinusitis,
there is recent evidence to suggest that
endoscopic sinus surgery alone may be an
effective treatment approach.
According to the indications, antibacterial drugs,
analgetics, hyposensitizing drugs (dimedroli,
suprastin, tavegil, loratadin)
 Chronical form of OMS. Clinical
picture.
A feature of odontogenic sinusitis is their
primary chronic course. When the maxillary
sinus communicates with the oral cavity
through the socket of the extracted tooth,
preceding symptoms of acute inflammation
often absent. The headache in patients is
not pronounced sharply, more often it is
intermittent, which is explained by the
limited localization of the process and the
outflow of exudate through the perforation.
So usually chronical form of OMS is
asymptomatic.
Chronical form of OMS. Clinical
picture.
CT-scan of patient with chronical form
of OMS and radicular cyst of 26

CT-scan of patient with chronical form of OMS and radicular cyst of 25

 Treatment of chronical odontogenic
sinusitis
With sinusitis, the altered mucous membrane is
removed and wide fistula between the maxillary
Removed of polyposis mucous membrane
sinus and the lower nasal passage for the
after sinusectomy
outflow of exudate in the postoperative period.
The most widespread is now radical sinusotomy
according to Caldwell-Luke, which is performed
under central or peripheral anesthesia with
neuroleptanalgesia.
Due to the above serious disadvantages of
sinusitis according to Caddwell-Luke with
odontogenic perforated sinusitis, in practice
performing a sparing variant of sinusectomy,
which consists of in the removal of polyposis
altered mucous membranes and preservation of
unchanged mucous membranes. The study of
the long-term results of surgical treatment of
odontogenic inflammation of the maxillary
sinuses using the method of sparing sinusitis
showed that complete recovery occurs in 96% of
patients
Treatment of chronical odontogenic
sinusitis
One of the most widespread forms of pathological process what dental-
surgeon can  meet in his practice also is the odontogenic maxillary
perforative sinusitis. In most cases it could be problem after iatrogenic
 interference or violation of rehabilitation period by the patient.
 Experience treatment patient with oroantral
fistula with the use of  PRF( Platelet Rich Fibrin) 
membranes.

Patient 33
years old.
Oroantral
fistula after
extraction in
area of 25-26.
Surgery steps (1-2).
Surgery steps (3-4).
Surgery steps (5).
Surgery steps (7). PRF-
membranes.
Surgery steps (8). Suturing.
 Others variants of Iatrogenic sinusitis

Foreign body in left maxillary sinus

Foreign body in right maxillary
– dental implant
sinus – dental implant
 Odontogenic Maxillary Sinusitis Of
Fungal Origin
CT of the patient with odontogenic 3D CT of the patient with odontogenic
maxillary sinusitis of fungal origin maxillary sinusitis of fungal origin
 Odontogenic Maxillary Sinusitis Of
Fungal Origin

Removed a fungal origin. Removed a fungal origin.

Complications of OMS
 Control questions:
1. A 36 year old man complains about acute headache, body temperature rise
up to 39,1C, indisposition. Objectively: a slight face asymmetry because of
soft tissue edema of the left infraorbital area. Crown of the 26 tooth is partly
decayed. Percussion is acutely painful. Mucous membrane on the vestibular
side in the area of the 25, 26 teeth is edematic, hyperemic. Breathing
through the left part of nose is labored, there are purulent discharges. X-
ray picture showed a homogeneous shadow of the left part of maxillary
sinus. What is the most probable diagnosis?
A. Acute purulent odontogenous maxillary sinusitis
B. Acute condition of chronic periodontitis of the 26 tooth
C. Acute periostitis of upper jaw
D. Suppuration of maxillary cyst
E. Acute odontogenous osteomyelitis
2. A 47 year old patient complains of permanent pain in the 27 tooth that is
getting worse during cutting. Objectively: the patient’s face is symmetric, skin
is of normal colouring, mouth opening is not limited, mucous membrane of
alveolar process is edematic and hyperemic at a level with the 27 tooth. The 27
tooth has a deep carious cavity communicating with pulp chamber. Percussion
of the 27 tooth causes acute pain. What is presumptive diagnosis?
A. Acute condition of chronic periodontitis of the 27 tooth
B. Chronic periodontitis of the 27 tooth
C. Acute general purulent pulpitis of the 27 tooth
D. Acute purulent periostitis of the upper jaw beginning from the 27 tooth
E. Chronic left-sided odontogenous maxillary sinusitis
 3. A 43 year old patient complained about mobility of his 24, 26, 27 teeth,
pus excretion from alveolus of the the extracted 25 tooth. 1,5 month ago dissection along the mucogingival fold was
performed and the 25 tooth was
extracted. Objectively: there is a slight swelling of soft tissues in the right
infraorbital area, lymph nodes of the right submaxillary area are enlarged,
slightly painful, nasal breathing is normal. Mucous membrane of alveolar
process in the area of the 24, 26, 27 teeth is edematic and cyanotic. There is
also a fistula with bulging granulations along the mucogingival fold.
Alveolus of the extracted 25 tooth excretes purulent granulations. What
disease does this clinical presentation correspond with?
A. Chronic localized osteomyelitis
B. Acute osteomyelitis
C. Acute condition of localized periodontitis
D. Acute condition of chronic maxillary sinusitis
E. Chronic alveolitis
4. A 43-year-old patient complains about constant pain in the upper
jaw region on the right, that irradiate to the temple. The pain was noted
one month ago. Objectively: the face is asymmetric because of the swollen
right cheek. Mucous membrane has no changes. The breathing through the
right nasal meatus is obstructed, there are foul-smelling purulent
discharges. Plan X-ray film of facial skeleton in the semi-axial projection
shows intensive opacity of the right maxillary sinus and violated
intactness of its interior and superior walls. What is the most likely
diagnosis?
A. Upper jaw cancer
B.Chronic odontogenic maxillary sinusitis
C.Chronic odontogenic osteomyelitis
D.Neuritis of the II branch of trigeminus
E.Upper jaw osteoma
 5. After super cooling a 42-year-old patient presented with headache in the
left frontal region and left upper jaw. Objectively: the face is symmetric,
breathing through the left nasal meatus is obstructed, sero-purulent
discharges are present. Palpation is slightly painful in the infraorbital
region as well as along the mucogingival fold in projection of the 24, 25
teeth. Percussion of these teeth is painless. The 24 tooth is filled.
Mucuous membrane of alveolar process has no visible changes. X-ray
picture shows reduced pneumatization of the left upper jaw si- nus. What
is the provisional diagnosis?
A. Exacerbation of chronic odontogenic maxillary sinusitis
B. Acute periodontitis of the 24 tooth
C. Exacerbation of chronic periodontitis of the 24 tooth
D. Acute rhinogenous maxillitis
E. Acute albuminous periostitis of the left upper jaw

6. After the extraction of the 26 tooth a 43-year-old patient presents with

a communication between the oral cavity and the maxillary sinus. X-ray
picture shows no changes in the maxillary sinuses. What tactics should be
chosen by a dental surgeon to prevent maxillary sinusitis?
A. Plastic restoring of the communication
B. Socket tamponade with a iodoform- gauze
C. Socket filling with a hemostatic sponge
D. Sinus rinsing with an antibiotic solution
E. Socket filling with a blood clot
 7. A 41-year-old patient complains of mobility of the 24, 26, 27 teeth,
purulent discharges from the socket of the extracted 25 tooth. 1,5 months
ago the patient underwent a dissection along the mucogingival junction and
extraction of the 25 tooth. Objectively: alveolar mucosa in the region of
the 24, 26, 27 teeth is cyanotic and edematic. Along the mucogingival
junction there is a fistula with protruding granulations. There are also
purulent granulation discharges from the socket of the extracted 25 tooth. In
the right infraorbital region some soft tissue swelling is present. Which
disease are these clinical presentations most typical for?
A. Chronic limited osteomyelitis
B. Chronic alveolitis
C .Maxillary actinomycosis
D. Exacermation of chronic maxillary sinusitis
E. Chronic diffuse osteomyelitis

8. A patient complains of heaviness in the left section of his head, pain in

the 26 tooth. Objectively: the crown of the 26 tooth is destroyed by 2/3 by
caries, the tooth percussion is weakly positive. X-ray picture of paranasal
sinuses shows definite unilateral dome-shaped veiling of the upper left maxillary sinus. On the X-ray picture of
the 26 tooth the periodontal fissure at the root apex is missing. What is the most likely diagnosis?
A. Radicular cyst ingrown into the maxillary sinus
B. Rhinoantritis
C. Odontogenic sinusitis
D. Cyst of the maxillary sinus mucosa
E. Malignant maxillary tumour
 9. A 64-year-old patient presents with bleeding from the left nostril,
mobility of the upper left teeth. For the last 2 years the patient has had
dull pain in the left side of maxilla. On the left side of neck there is a
dense tumour-like formation. The patient is exhausted. What is the most
likely diagnosis?
A. Left-sided maxillary carcinoma
B. Left-sided sinusitis
C. Left-sided maxillary cyst
D. Chronic osteomyelitis of the left upper jaw
E. Osteoclastoma of the left upper jaw

10. After the clinical and radiographic examination a 32-year-old patient

was diagnosed with chronic odontogenic sinusitis, fistula between sinus
and oral cavity through the socket of the 27 tooth. Specify the optimal
method of surgical treatment of this disease:
A. Radical maxillary sinusotomy and local tissue plasty of fistula
B. Local tissue plasty of fistula, anti- inflammatory therapy
C. Radical maxillary sinusotomy
D. Fistula plasty with a hard palate graft
E. Fistula suturing